Health Matters: The Role of Health and the Health Sector in Place-Based Initiatives for Young Children November 2008

Transcription

1 Health Matters: The Role of Health and the Health Sector in Place-Based Initiatives for Young Children November 2008 Prepared for The W.K. Kellogg Foundation by Amy Fine, MPH and Molly Hicks, MPA

2

3 ABOUT THE AUTHORS Amy Fine is an independent health policy and program consultant with over 25 years of experience working on issues related to maternal and child health, public health and health safety net programs. Her expertise includes: policy and program analysis, strategic planning, program planning, preparation of issue papers, and planning and facilitation of learning collaboratives. Ms. Fine has authored numerous reports, including strategic assessments of the federal Maternal and Child Health Bureau s major discretionary grant programs: Healthy Start and Special Projects of Regional and National Significance (SPRANS). Current and recent clients include: the W. K. Kellogg Foundation, Nemours Health and Prevention Services, the Commonwealth Fund, the American Academy of Pediatrics, and the Institute of Medicine. At the federal level, she has worked extensively with the Health Resources and Services Administration. Prior to becoming a consultant, Ms. Fine s held positions at the Association of Maternal and Child Health Programs, the Center on Budget and Policy Priorities, and the University of North Carolina s Child Health Outcomes Project. She holds an undergraduate degree in nursing from the University of California, San Francisco, and a Master of Public Health degree from the University of North Carolina. Molly Hicks (mhicks@keenemillconsulting.com) is an independent health policy consultant with more than 12 years of experience working on issues related to maternal and child health. Her expertise includes child health advocacy, health communications, coalition building, project development, grants management, and strategic planning. Current and recent clients include: the W.K. Kellogg Foundation, American Bar Association s Center on Children and the Law, American College of Preventive Medicine, American Academy of Pediatrics, The Johns Hopkins University Urban Health Institute, and the Institute of Medicine. Prior to becoming a consultant, Ms. Hicks served as Assistant Director, American Academy of Pediatrics Department of Federal Affairs. She previously held positions with a number of federal agencies. Ms. Hicks earned her undergraduate degree from Clark University in Worcester, Massachusetts and her Master of Public Administration degree from The George Washington University in Washington DC. ACKNOWLEDGMENTS The authors wish to thank Al Yee, Program Director at the W.K. Kellogg Foundation, whose vision, support, and guidance made this study possible. We are also indebted to the key informants, as well as the program innovators from our eight study initiatives, whose insights and experiences form the basis of this monograph. iv

4 EXECUTIVE SUMMARY Study Goals This study provides an initial scan of the role of health and the health sector within broader place-based initiatives for young children. The long-term goal of the study is to better link children and families to the full array of services and supports needed to promote healthy growth and development. The more immediate goal is to assist program planners and implementers, policy makers, funders and other key stakeholders in identifying, understanding and promoting the role of health and the health sector within innovative, multi-sector, place-based initiatives that serve children and their families. Landscape for Early Childhood Initiatives Two pulls new knowledge and increased challenges have created for many a new sense of urgency and action around early childhood. In part, this reflects recent scientific findings about brain development and developmental trajectories, both of which provide new insights into the interplay between genes and environment and the importance and life-long impact of healthy development in the early years. At the same time, today s young children and their families as well as those who provide services and supports to children and families are facing new and increasing challenges, as evidenced in several spheres, including education, health, and family functioning/family support. The emerging focus on early childhood is evident in programs and projects across the country, and across multiple sectors. However, all too often, the pieces don t fit together: in many instances the various sectors seem to be engaged in the parallel play stage of development; that is, working side-by-side but with little or no interaction. In other cases, where early childhood efforts do cut across sectors, it appears that the health sector is either not actively engaged, or simply missing-in-action. Thus, an initiative might work to ensure children get health coverage, but there is not necessarily any interplay between health care providers and others working to improve developmental trajectories for children. Likewise, while federal and state systems change initiatives are increasingly common, these initiatives are not always embraced or owned at the local level. Nevertheless, there are positive developments. Heightened activity for early childhood is a promising starting point. Moreover, there are existing multi-sector, place-based initiatives, which are, in fact, putting the pieces together in support of young children and their families. Study Initiatives This study identifies and describes eight exemplary, early childhood initiatives, all of which include a strong and active health component, and have successfully integrated efforts across multiple service sectors and settings. The study initiatives include: Children and Families Commission of Orange County (CA), Children s Board of Hillsborough County (FL), Children s Futures (Trenton, NJ), First 5 Ventura County (CA), Help Me Grow (CT), Opportunity Knocks (Middletown, CT), Region A Partnership for Children (Western NC), and Westside Infant-Family Network (Los Angeles, CA). In addition to providing an in-depth profile for each of the eight initiatives, the study report also describes common cross-initiative themes, strategies, and program elements. Cross-Initiative Program Framework In order to better understand and describe how multi-sector, place-based initiatives for children are organized, the study sought to identify the basic program framework for each initiative, along with key v

5 program elements. While there is a great deal of variation in specific program implementation, with individual services and approaches tailored to meet local circumstances, there is also remarkable consistency in the overall program framework across the initiatives, including three core service sectors, four key audiences, and three primary program strategies. Each of these basic program building blocks is described in further detail in the report. Health Matters: Cross-Initiative Program Framework Core Sectors Key Audiences Primary Program Strategies Health Education Family Support Children Parents/Family Providers Community/Community Systems Enhanced Services Capacity Building Systems Change and Integration Health Sector Engagement in Systems Change and Integration Systems change and integration play a special role in the exemplary multi-sector, place-based initiatives highlighted in this study. This primary program strategy helps the study initiatives move from a collection of individual service and capacity-building projects to an integrated set of programs that work at a community-wide level. In keeping with its focus on the health sector, the study further examines the role of the health sector in systems change and integration. This includes health sector engagement at three levels: 1. Systems Change/Integration within the Health Sector. Within the health sector, services are strengthened, expanded and vertically integrated. 2. Changes in the Interface between Health and Other Sectors. Across sectors, health services are better linked and horizontally integrated with other existing services. 3. Health Sector Engagement in Community-Wide, Cross-System Change/Integration. At the community systems level, the health sector is engaged in community-wide/cross-systems planning, service development, and policy change. Summary Findings Key study findings include the following: Innovative, multi-sector initiatives for young children that include an active role for the health sector do exist, and they are making a difference. While health sector engagement in broader place-based initiatives is not yet the norm, this review points to the important roles these initiatives and their health components can play in improving the lives and life trajectories of young children and their families. These initiatives serve as platforms for engaging families, service providers and communities in promoting healthy development; improving services and service delivery within individual sectors; organizing and delivering integrated services across sectors; and working toward broader policy and systems change to better meet the needs of children and families. Several common building blocks lay the foundations for multi-sector collaboration, coordination and integration within place-based initiatives for young children. These include a vi

6 whole child/whole family focus; funder-driven collaboration; the initiatives role as a neutral convener/facilitator; multi-sector community-based planning and engagement; and an underlying service philosophy that focuses on going where the children are. While there is a great deal of variation in specific program implementation, with individual services and approaches tailored to meet local circumstances, there is also remarkable consistency in the overall program framework and key program elements across the initiatives. This includes consistency in core service sectors (health, education, and family support); key audiences (children, parents/family, providers, community/community systems), and primary program strategies (enhanced services, capacity building, and systems change/integration). Although the study initiatives have different frames, all work toward improving health and healthy development, as broadly defined. Specifically, the initiatives fit well with the broad definition of health proposed in the National Academy of Sciences report, Children s Health, the Nation s Wealth. Applying this definition helps to clarify the ways in which these and other broad, place-based initiatives for young children intersect with health, and may make it easier to engage the health sector. The health sector plays an important role in the study initiatives, helping children realize their full developmental potential: physically, emotionally, socially and cognitively. As part of placebased early childhood initiatives, health professionals promote healthy development using the same key strategies, focused on the same audiences as the other sectors. In addition to providing direct services through traditional clinical settings, health sector players also provide clinical services in non-traditional settings; offer parent education classes; promote early literacy; link children and families to additional services and supports in their communities; provide home visiting consultation and therapeutic intervention; provide consultation to service providers from other sectors; collect and analyze data on service needs and gaps; and work to develop new or enhanced services that address the health and developmental needs of children in the communities they serve. Participation in broad, place-based initiatives plays an equally important role in strengthening and transforming the health sector. As part of broader place-based initiatives for young children, health professionals and other key players are engaged in systems change at three levels: within the health sector; between health and other sectors; and at the community-wide/cross-systems level. Health sector systems change at these three levels has strengthened and transformed health sector roles, services, capacities and impact within communities. The success of these initiatives does not rest on a single sector, audience, or strategy. Rather, it is the initiatives ability to integrate their broad program strategies across multiple sectors and audiences that sets them apart. The concept of an integrated strategic framework is central to this study and report. What the initiatives share in common is the kind of funding, framing, and political will needed to implement integrated program strategies across multiple services and sectors. This means that initiative leaders (i.e., lead staff, advisory boards, and funders) plan for their initiatives in ways that link and reinforce program approaches and relationships across sectors. Examples include: using the same key messages across sectors and audiences; developing cross-sector referral-linkage and data systems; and using cross-sector training to improve basic service capacities and to enhance relationships across sectors. The level at which individual service providers are engaged in working directly with other sectors varies by initiative, by program, and by provider. Some providers have literally moved into new service settings (e.g., moving clinical care or consultation to an early childhood center or school); or are now part of a broader early childhood provider team in a community setting; or are part of a vii

7 cross-discipline team that is drafting a consistent set of messages for young children and their families community-wide. In other instances, individual providers may continue to work in their specialized settings, but receive direct assistance from other service providers; or providers may have access to online data from partner agencies serving the same clients; or they may be on the receiving end of new referral/linkage pathways. The point is that by developing strategically integrated program frameworks, these initiatives are putting the pieces together for children, families and service providers; and they are effectively using their resources to achieve outcomes that cannot be achieved one sector at a time. The cross-initiative program framework, key program elements, and basic building blocks for multi-sector collaboration, coordination and integration identified in this report have been successfully used across the initiatives, and therefore it is likely that they can be applied successfully elsewhere, as well, particularly when coupled with the kind of flexible implementation that has allowed the study initiatives to adapt and tailor their work to the specific circumstances of the communities they serve. Financing has played a key role in shaping the study initiatives. In most cases, the study initiatives have benefitted from a significant source of start-up funding that not only allowed, but actually promoted collaboration, coordination and integration of services, as well as program strategies, for the benefit of young children. For many of the initiatives, financing has covered far more than the usual grant period of one to three years; extending to ten years or more. Also of note, funding for the study initiatives has not been tied to a single, pre-existing agency or sector. Instead, for most of the initiatives, funds were awarded to a new entity, which has allowed that entity to serve as a neutral convener and facilitator across agencies and sectors. Sustainability remains an ongoing issue even for the effective and successful initiatives in the study. All of the initiatives that were studied face serious questions about their long-term sustainability. Several are dependent on time-limited private grants, and even for those that have obtained public financing, revenue sources are far from secure. The consensus among study initiatives and national experts participating in the Health Matters meeting in April 2008 is that, ultimately, macro-level systems and policy changes will be needed to sustain these and similar initiatives in the long run. Conclusions This review leads to four overarching conclusions: The study initiatives and others like them provide effective platforms for improving the lives of young children and their families, promoting healthy development, and transforming child health and other service systems in the communities where they have been implemented. As such, they can serve as models for transforming child and family services, supports, programs and policies nationwide. With adequate support and resources, place-based initiatives such as those profiled in this study can also serve as innovation incubators, testing new ideas, establishing new approaches within and across service sectors, and finding new ways to build capacity within families, service sectors, and communities. In this way, the place-based, multi-sector initiatives can make important changes within their own geographic boundaries, and build an evidence base that can help guide other communities, program planners and implementers, funders, and policy makers nationwide. viii

8 Health sector participation in multi-sector place-based initiatives for young children should be promoted and further developed, both as a means of strengthening multi-sector initiatives and their impact on children, and as a means of improving the health system. Long-term issues around financing and sustainability suggest that broad policy and macrolevel systems changes (at the local, state and national levels) will be needed to sustain these and similar initiatives in the long run (including sector-specific changes currently supported by the initiatives). Therefore, there is a need to identify current and potential policy options for longterm sustainability, build an evidence-base around these options, and build political will to support needed policy and systems changes. Recommendations The report includes four major recommendations organized around the study s four key conclusions. Potential starting points are also offered for each of the following recommendations: 1. Further explore and disseminate information on the eight exemplary initiatives highlighted in this report, and others like them, as models for transforming child and family services, supports, programs and policies nationwide. This study serves as an introduction to multisector, place-based initiatives for young children, with a particular focus on the role of health and the health sector within the initiatives. As such, it is a first step. Many additional aspects of these and similar initiatives can and should be further explored and described so that others can build on their work. 2. Develop and provide the support and resources needed to help these and similar initiatives become innovation incubators, testing new ideas, establishing new approaches within and across service sectors, and finding new ways to build capacity within families, service sectors and communities. Beyond capturing and disseminating what has already been done, there is a great opportunity to work collaboratively with existing initiatives in order to jointly problem solve, test new ideas, and build an evidence base for successful interventions. 3. Promote and enhance health sector participation in multi-sector, place-based initiatives for young children, both as a way to strengthen the initiatives and their impact on young children, and as a means of improving the health system. Multi-sector, place-based initiatives for young children provide an extraordinary opportunity for health professionals, health care services, and public health programs to: (1) expand and strengthen healthcare services; (2) build capacity; and (3) change and integrate systems of care (within the health sector and between health and other sectors). In addition, the study initiatives, and others like them, can provide the resources and opportunities needed to rethink and realign healthcare content, organization, and delivery (including delivery sites). 4. Identify, develop and promote policy and systems changes for long-term sustainability. Ultimately, broad policy and systems changes will be needed to sustain most of the study initiatives, and others like them, so that multi-sector, collaborative, place-based and communityowned efforts can become the norm. ix